Urology Coding Alert

Question: Is there an ICD-10-CM code for a systemic Bacillus Calmette- Guerin (BCG) infection? My urologist calls this condition “BCG-osis.” In this specific case, the patient had a BCG instil­lation to treat transitional cell carcinoma (TCC) of the bladder. The original diagnosis code reported for the BCG encounter was C67.9 (Malignant neoplasm of bladder, unspecified). Several weeks later the patient returned to the office with an infection as a result of the BCG instillation. What diagnosis code should I use for the encounter for the BCG infection?

Georgia Subscriber

Answer: There is no specific ICD-10-CM diagnosis code for the infection resulting from the BCG instillation. This side effect is rare in occurrence. The best code to report for this infection is N30.00 (Acute cystitis without hematuria). In addition, report the bladder cancer code: C67.9 (Malignant neoplasm of bladder, unspecified). Then, report T88.7 (Unspecified adverse effect of drug or medicament) to indicate the infection is caused by the BCG.

There is also a “use additional code for adverse effect, if applicable, to identify the drug” note with the T88.7 code. In this case, report T50.Z95 (Adverse effect of other vaccines and biological substances).

Note: There are specific codes for locations of the bladder neoplasm. If the documentation does not state a particular area of the bladder, then the unspecified code is appropriate. See neoplasm codes under C67 for the specific locations of bladder cancer.